CVU SUMMER PROGRAM: CONSENT FORM

EMERGENCY HEALTH INFORMATION

STUDENT & GUARDIAN NAMES

EMERGENCY PHONE

STUDENT’S PHYSICIAN

PHYSICIAN’S PHONE

INSURANCE COMPANY

POLICY #

LAST TETANUS SHOT ON

LIST OF ALLERGIES

ADDITIONAL COMMENTS (attach additional page if needed)

Should it become necessary for my child’s program director or other CVU official supervisor to get medical treatment and I cannot be reached, I authorize such treatment to be performed.  I have verified all the names, numbers, and policies listed on the Emergency Information form are current and reliable. Signature of parent/guardian:  _______________________     Date:  __________

TRANSPORTATION CONSENT I hereby give permission for my son/daughter/ward to travel by a Chittenden South Supervisory Union staff member's bus/vehicle to pickup or deliver a student home on occasion. Signature of parent/guardian: ______________________     Date:  __________

PUBLICITY RELEASE I give permision to Chittenden South Supervisory Union to use my son/daughter/ward’s name or photo in local newspapers, school newsletters or video/photo/slide productions. Signature of parent/guardian:  _______________________     Date:  __________

CONSENT STATEMENT I, _______________________________________ (student name) understand CVU will be a safe place for all participants and that the use of any form of tobacco, alcohol, drugs, illegal substances of any kind, or perceived dangerous uses of any materials are not acceptable.  I understand the staff has a zero tolerance policy.

Furthermore, I understand every person must feel safe in order to learn.  I will be able to respect myself, others, and the property in order to promote a safe learning environment.  Negative physical behaviors are not acceptable.  I understand taking full responsibility for my actions is expected.

Student signature:  ___________________________   Date:  ___________

I hereby give permission to said son, daughter, or ward to participated in CVU Summer Programs based on the Consent Statement listed above.

Parent signature:  ___________________________   Date:  ___________